Endgames Case Review

A persistent vulval ulcer

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5421 (Published 16 October 2015) Cite this as: BMJ 2015;351:h5421
  1. Catriona M Maybury, dermatology registrar1,
  2. Andrew Pink, National Institute for Health Research academic clinical lecturer2,
  3. Fiona Lewis, consultant dermatologist1
  1. 1St John’s Institute of Dermatology, Guys and St Thomas’ NHS Foundation Trust and Kings College London, London, UK
  2. 2Department of Medical and Molecular Genetics, Kings College London
  1. Correspondence to: C M Maybury Catriona.maybury{at}kcl.ac.uk

An 84 year old woman presented with a seven month history of a gradually enlarging, tender, shallow ulcer on the outer aspect of the right labium majus (fig 1). She reported no other active or previous skin or mucosal problems and had a background of ischaemic heart disease, hypertension, hypercholesterolaemia, and type II diabetes. She was taking lisinopril, indapamide, atenolol, atorvastatin, aspirin, isosorbide mononitrate, nicorandil, metformin, and omeprazole. She was a non-smoker and there was no family history of skin disease.

Questions

  • 1. What should you cover in the history and examination of a patient with vulval ulceration?

  • 2. What differential diagnoses should you consider in a patient with vulval ulceration?

  • 3. What investigations might help you make a diagnosis?

  • 4. How would you manage this patient?

Answers

1. What should you cover in the history and examination of a patient with vulval ulceration?

Short answer

Take a detailed history. A thorough examination of the vulva, vagina, and perianal area is needed, followed by a general skin examination, including other mucosal sites.

Discussion

Ask about the onset, triggers, and duration of the ulcer as well as the presence of fever or systemic symptoms. Has the patient had a previous episode? Does the patient have any other immune mediated problems? What personal care products does the patient use? Have smear test results been normal? Does the patient have a new partner? A full drug, sexual, and travel history could give important clues.

Examine the vulva, noting the number and size of ulcers. Is there associated excoriation, fissuring, or oedema? In addition, examine the vagina, perineum, perianal skin, and inguinal lymph nodes. A general examination of the skin, eyes, and mouth may also provide vital clues to the diagnosis. For example, eczema at other sites may raise the possibility of contact dermatitis.

2. What differential diagnoses should you consider in a patient with vulval ulceration?

Short answer

Differential diagnoses include infection (such as herpes simplex), inflammation, cancer, trauma, and iatrogenic (drug induced) causes. Infection is a more …

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